It makes sense to sell this old place now, but he can’t bring himself to leave her ashes.

Barry Gibbs lives alone in a single-story home among the loblollies of Hyde County in eastern North Carolina. The army veteran collects a small disability check after he tore tendons in his shoulder during a fall at his maintenance job at the local school. He winces every time he stands up. He’s 64 years old and the closest hospital is more than an hour away, a distance he came to understand too damn well on the day she needed help.

Their wedding portrait still hangs on the living room wall. It’s one of those 1980s shots with the laser beam backgrounds, her hair big and his mustache combed, his hand on her shoulder. The interior of the house is almost as she left it four years ago: white oak floors, paintings of black bears, family Christmas photos on end tables.

Outside along the driveway, a line of cypress trees shades a headstone that marks where Barry cut a ditch and spread Portia’s ashes, right where she asked to be.

Everybody called her Po. She was picking up sticks from the yard on 7 July 2014, five days shy of her 49th birthday, when she felt a sharp pain in her chest.

Six days earlier, their community hospital had closed. Pungo district hospital was 47 miles west of their house, in Belhaven, and had served the county since 1949, back when crab-picking plants and lumber mills kept these small waterfront communities working.

A picture of Barry Gibbs and his wife Portia. Photograph: Justin Cook for the Guardian

If you’re an accountant, hospitals are only as good as the number of paying patients. Belhaven’s population is about half what it was then. And Hyde county is now the fifth-sparsest county on the east coast, with nine people per square mile.

This spongy stretch of North Carolina’s inner banks represents the suffering side of a modern migration pattern in which southern cities are flourishing, but rural areas are shrinking and losing healthcare options. Since 2010, 53 ruralhospitals have closed in 11 southern states, compared with 30 in the other 39 states. About half of those southern closures occurred in counties where non-whites make up a larger percentage of the population than they do the rest of the country. All but two happened in counties with poverty rates above the national average.

In Humphreys county, Mississippi, for instance, three-quarters of residents are black and nearly 40% live in poverty. The hospital there closed in 2012. In Barnwell county, South Carolina, which lost about 6% of its population from 2010 to 2017, residents learned on Facebook in January 2016 that their hospital would shutter the following day.

Many people in these areas piece together incomes with contract jobs that don’t offer insurance. Hospitals are often left to pay the bills for the poorest and sickest, and the math worsened as legislatures in the region rejected Medicaid expansion under the Affordable Care Act. The non-partisan Kaiser Family Foundation acknowledged in March that Medicaid is having a “disproportionately positive impact in rural areas in expansion states”. The forces combine to create an unequal healthcare landscape, with urban hospitals producing an average 6% profit each year, while rural hospitals are at 2%.

In June, the hospital in Jacksonville, Alabama, will be the first rural hospital to close in 2018. While the deceleration of closures should be an encouraging development, rural health champions wonder if it will make lawmakers less likely to help the areas left behind.

For people in those areas, the questions are more personal: when does a financial decision outweigh a moral obligation? How far out is too far out for you to care about us?

Standing on the porch with Po that torpid July day, Barry had two options: he could go 60 miles east to a hospital in Nags Head and lurch along in the Outer Banks summer congestion, or drive 70 miles west, past Belhaven to a hospital in the town of Washington, where he knew the roads and their doctors had moved.

It wasn’t even a question.

Barry helped Po to their white Buick, backed out of the driveway, turned west toward Washington, and slammed the gas pedal.

‘I’d rather die en route to my doctors’

When Vidant Health, a $1.6bn non-profit medical consortium which owns all of the other hospitals in this region, purchased Pungo district hospital in 2011 and determined that it was losing money, few here were surprised. But when Vidant announced Pungo’s closure in 2013, it started a bitter four-year conflict that spurred protests, marches to the nation’s capital, NAACP intervention and lawsuit upon lawsuit.

“It’s worse than murder,” Adam O’Neal says, standing over his kitchen sink deveining shrimp. “Everybody who needs emergency care and is dying is being murdered by Vidant.”

The former mayor of Belhaven, Adam O’Neal, stands at the empty lot where Pungo district hospital once stood. Photograph: Justin Cook for the Guardian

O’Neal served as Belhaven’s mayor for 12 years before deciding not to run in 2017.

Two weeks after the hospital closed in 2014 – one week after Po died – O’Neal staged a 273-mile walk from Belhaven to Washington. He did it again the next year, and was joined by medical professionals from rural hospitals across the south, as well as activists, including Freedom Rider Bob Zellner.

He’s a white Republican who won six terms as mayor in a town that’s nearly 60% black and stood alongside the Rev William Barber, a prominent civil rights activist who spoke at the 2016 Democratic national convention.

The protests created a small pool of enemies at home for O’Neal. Opponents worried his red-hot style would lead Vidant to back out of an agreement to build a modest multispecialty clinic in the hospital’s absence. (In my weeklong trip to the area in March, people called O’Neal a “bully”, a “dictator” and an op-ed in the local paper last year called derided him as “the town crier”.)

As he flops the shrimp around in a plate of flour, O’Neal fires off on those who didn’t support the campaign – everyone from the former Republican governor to small business owners in town. He refers to studies like one the Centers for Disease Control and Prevention released last year, which showed that rural white populations have better access to care than rural minority populations.

“By me treating the blacks just like I did the whites, that makes people furious,” he says. “When you treat everybody the same, you better get ready, because people will come at you.”

On Christmas Eve 2016, in a final effort to save the building, Barber wrote a column for the website Red Letter Christians titled, A Christmas Carol in Rural America. He prayed for an injunction and wrote: “No matter how long we’ve ignored our poor and sick neighbors, we can learn to do right.”

Five days later, Vidant demolished the hospital.

It’s been more than a year, and quiet fills spaces where conversations used to happen. Lifelong friendships are wrecked in a town where it’s hard to avoid each other. Neighbors who used to dance and bid on East Carolina University-themed crab pots together at hospital fundraisers now turn their backs toward each other at the downtown diner.

If you drive east, Belhaven is the last town of more than 1,500 people until you reach the coast. One-hundred and twenty-five miles of winding pavement separates the beach hospital in Dare county and the one in Washington. Eastern Hyde county, where Barry lives, is right in the middle. Paramedics there are directed to take patients to Dare county, because it’s technically a shorter trip. But Hyde county natives are programmed from birth to avoid beach traffic, so they keep most of their regular doctors in Washington or even farther west.

Barbara Gibbs, Barry’s third cousin, is a 73-year-old former social worker. When she learned that calls to 911 would result in her being sent to Dare county, she told her husband that if she has an emergency he shouldn’t pick up the phone – he should drive her to Washington.

“I’d rather die en route to my doctors than go to Dare county,” she says.

‘Everything is about distance’

Seven miles into the frantic drive with Po, Barry came to an intersection with NC Highway 94, the only road that crosses the 40,000-acre Lake Mattamuskeet.

Po rolled down the window and threw up. Barry knew she wouldn’t make it to Washington. He called the EMT station on the other side of the lake and said he was on his way.

Lake Matamuskeet in Hyde county, North Carolina. Photograph: Justin Cook for the Guardian

It’s a straight shot across, six miles. As a teenager, Barry drag raced friends on the road at 140 miles per hour. Now he was in his 60s, flooring it again, zooming past people fishing for crappie and perch under the July sun. Only this time, his wife was next to him having a heart attack.

They’d met at the Sound Side Dance Hall in the early 1980s. He was in his late 20s and had served seven years as a US army infantryman, been married and divorced. She was just 18 but had her share of life experiences, too. She was born to parents in northern Virginia who named her Laura Sue Norris then gave her up for adoption. Her adoptive parents changed her name to Patricia Swindell, and her nickname evolved into Portia, then Po.

She tried to find her birth parents several times. She discovered her original birth certificate and paperwork that listed their likes and dislikes, but never uncovered a name or number. “She always wanted to know,” Barry recalls.

Barry and Po married on New Year’s Eve in 1987 and had a son three years later. Six years after that, a daughter. Po was never in great health. She was a diabetic from childhood. She had begun to show signs of multiple sclerosis. Sometimes Barry found her lying in the yard with no way of explaining how she got there.

They’d made it through each episode, though, so as he sped across the lake Barry never considered that she might not make it home.

They were 34 miles from where Pungo hospital had been open just a week earlier, and 60 from Washington, when he pulled into the parking lot of Mattamuskeet school, which housed an EMT station.

They put Po into an ambulance and shut the doors. Barry waited behind the vehicle for “over an hour, hour and a half” before an EMT popped out and said they were moving her across the lot to meet a helicopter from Greenville. Barry followed the ambulance and looked up.

Just as the chopper was landing, the EMTs told Barry that Po was gone.

‘We’re a real town because we have a hospital’

On a recent spring afternoon along a creek that leads to the Pamlico Sound, local shrimpers were readying their boats for the season. Terrell Mackey was helping friends on the Capt Dell.

Mackey is a 37-year-old black man who was born in Pungo district hospital. He served in the army after high school, and now raises two young sons on the northern edge of Belhaven. He’s an auto mechanic who delivers seafood on the side.

“Pretty bad,” he shot back when I asked him how things are after the hospital closed. “They took away something that was helping locals. Around here, everything is about distance.”

In June 2016, Vidant opened $5.9m multispecialty clinic with 19 exam rooms in Belhaven. It has eight full-time providers for primary care, physical therapy, lab tests and other appointment services. It’s open 24 hours a day but doesn’t have an emergency room. The overnight staff often consists of one physician’s assistant or nurse practitioner. There’s a helipad outside, and local EMS is directed to take people there in an emergency.

Vidant’s mission is “to become the national model for rural health and wellness”. Around the country, rural systems are trying to customize care for specific communities. One area may need just an emergency room, for instance, but another may need more outpatient services. You wouldn’t build a shopping mall for a town that can support only one department store, after all.

Ricky Credle, an independent who was elected Belhaven’s new mayor in November, says the clinic works for now. It had nearly 29,000 visits from patients last year, and a recent third-party survey showed that 85% rated their experience highly.

“I’m pretty sure there’s a lot of rural areas in North Carolina and all across America that would be glad to have a clinic like that,” says Credle, a black man who runs an auto detail business. Credle says his goal is to bring in businesses and jobs to attract new residents. Maybe then, he says, Vidant will open an emergency room.

Entering Hyde county, North Carolina. Photograph: Justin Cook for the Guardian

Dan Drake, Vidant’s senior vice-president of operations, says the group is expanding the emergency department in Washington, but has no plans to reintroduce one in Belhaven. “We know that we are seeing an increase in patients that are using this clinic,” Drake says. “The people who live there and work there and serve those people are proud of what they’re doing.”

Still, the most consistent feelings I gathered in conversations with more than 40 people around the region were apprehension and skepticism. Several, such as Barbara Gibbs, said they were desperate for an emergency room.

Mackey, on the docks, lives less than a mile from the clinic and went there with pain in his knee recently. “Basically, they gave me an Ace bandage, but when that bill came, it was $900,” he says. “If you don’t have a fancy insurance policy or a crisp $100 bill in your pocket, you’re going to get treated different.”

On Father’s Day last year, a two-year-old boy with a mop of black hair was playing in his yard in Hyde county when a copperhead snake slithered out from under a toy car and bit him. His mom, Hannah Berry, sped 20 miles to the clinic. Staff there told her to drive to Washington, and staff there ordered an airlift to Greenville. Finally, after two car rides and a flight, the boy received anti-venom. It was at least two hours after he started screaming, Hannah recalls.

Last July, Latoya Chase took her elderly mother to the clinic with chest pains. When Chase went inside for help, “they told me that I needed to call 911,” she says. She called, and they waited in the parking lot for paramedics. Chase’s mother survived – doctors found blood clots, not a heart attack – but Chase remains furious. “Going there is a waste of time,” she says of the clinic.

Sally Holton, an 89-year-old retired schoolteacher, went to the clinic with breathing problems in 2016 and says doctors called hospitals in Washington and Greenville. Neither had room. They sent her farther west, to a Vidant-owned hospital about 75 miles west of Belhaven.

“I have been in a mess without the hospital,” Holton says. “I’ve just been handicapped.”

Dr Mark Holmes, a professor at UNC, is director of the North Carolina Rural Health Research and Policy Analysis Center. A challenge with studying the effects of a rural hospital closure, he says, is that deaths are the only health statistic that’s easy to track.

His team can study economics – there’s a 4% drop in per-capita income and an increase in unemployment by 1.6% after one closes – but there’s no way to count the people who stay home sick when they should see a doctor, or how many visits a family would make if a patient was closer to home. The toll on relationships is impossible to quantify.

“Imagine Green Bay without the Packers,” Holmes says. “It’s a similar type of thing: We’re a real town because we have a hospital. We’re a real city because we have a professional athletic team. Those things give social fabric, which we know is important to a healthy community.”

The building’s outline remains. The weather-worn asphalt in the parking lot cuts and juts around grass: a horseshoe where an entrance once welcomed visitors, a sidewalk to the emergency room, all paths to nowhere now.

The non-profit group that controls the property is selling it to a developer for $525,000. There’s potential. Belhaven’s waterfront sparkles. A block away are a couple of rows of big homes with front porches, and handful of restaurants that serve local seafood. Boaters passing through along the Intracoastal Waterway will stop in and eat this summer.

The newest business in town is an ice cream shop started by Credle and his daughter, Shaiana. Sweet Tooth opened on 30 March, and Shaiana smiled as she sold two scoops of salted caramel to the first customers.

“It’s not the end of the world,” the new mayor says of losing the hospital. “When the schools left, they said that’s the end of Belhaven. Guess what? We’re still here. When the crab industry left, people said Belhaven is dying. Guess what? We’re still here. Well, the hospital closed and guess what? We’re still here.”

That general status report is something most people can agree on, even Barry Gibbs, as he winces and picks up sticks around Po’s headstone, counting the reasons to move.